Advanced wound site management systems and methods

ABSTRACT

An introducer comprises a sheath, a guide rod, at least one wire stabilization guide, and a loop actuation wire for securing and centering a wound opening during a medical procedure (e.g., wherein a transluminal device is utilized) and during closure of the wound. The guide rod is sized to fit within the inside diameter of the sheath. The guide rod has at least one slot along its length for releasably holding the loop actuation wire. One or more wire stabilization guides or elongated members are coupled to the sheath. In one exemplary embodiment, the elongated members may be actuated to form a loop, so that when the sheath is approximated to a wound site, the loop portion is approximated to tissue surrounding the wound site to hold the sheath approximately centered on the wound site. A method for identifying the depth of insertion of a transluminal device into an artery or vein based on the presence of pressurized blood internal to the vessel and the absence of pressurized blood external to the vessel is also provided.

CROSS-REFERENCE TO RELATED APPLICATION

[0001] The present invention is a continuation-in-part of applicationSer. No. 09/658,786, filed Sep. 11, 2000, now U.S. Pat. No. ______ andassigned to the same assignee.

BACKGROUND OF THE INVENTION

[0002] 1. Field of the Invention

[0003] The present invention relates to a wound site management, for useduring and after an invasive medical procedure. More specifically, thepresent invention relates to wound site management techniques andmethodology for diagnostic and interventional procedures occurring at awound site, for example, a puncture made in the wall of an artery orvein during a medical procedure. The puncture may be the result of acatheter-based intervention, although any puncture is contemplated,accidental or intentional. The present invention has particular utilityfor use in and around the femoral, radial, and brachial arteries aftercoronary/cardiac procedures. Other utilities include soft-tissueanchoring, tendon and artery joining, meniscal repair, thoracic lungclosure, heart repair, endoscopic procedures, esophageal repair,laparoscopy, skin/epidermal wound closure and general tissue closure.

[0004] 2. Description of Related Art

[0005] Catheters/catheterization procedures are well known, andtypically involve insertions through the femoral artery for diagnosis orto treat cardiovascular and/or peripheral vascular diseases. After adiagnostic or interventional catheterization, the puncture formed by thecatheter must be closed. The puncture opening in the artery typicallyranges from 5F for a diagnostic procedure to 6-10F for an interventionalprocedure. Traditionally, intense pressure has been applied to thepuncture site for at least 30-45 minutes after removal of the catheter.Other approaches include a thrombotic or collagen plug, and/or othersuturing methodology for sealing the puncture. Patients who have had afemoral puncture are then required to remain at bed rest, essentiallymotionless and often with a heavy sandbag placed on their upper legs,for several hours to ensure that the bleeding has stopped. Thistraditional method of hemostasis following femoral artery access hasmany inadequacies. When a blockage is removed during a procedure, thepatient quickly feels better and they often have more energy than theyhave had in years, but they must remain motionless for several hours.The weight of the sandbag on the femoral artery often causes the lowerleg to tingle or go numb. The recovery time from the medical proceduremay be as little as ½ hour, but the recovery time from the wound canexceed 24 hours. The longer the recovery time, the more expensive theprocedure becomes, the greater the patient discomfort, and the greaterthe risk of complications.

SUMMARY OF THE INVENTION

[0006] It will be appreciated by those skilled in the art that althoughthe following Detailed Description will proceed with reference beingmade to preferred embodiments, the present invention is not intended tobe limited to these preferred embodiments. Other features and advantagesof the present invention will become apparent as the following DetailedDescription proceeds, and upon reference to the Drawings, wherein likenumerals depict like parts, and wherein:

BRIEF DESCRIPTION OF THE DRAWINGS

[0007]FIGS. 1-3 are isometric views of one embodiment of the staple ofthe present invention in formed, opened and deployed positions,respectively;

[0008]FIG. 3A depicts an isometric view of alternative staple of theembodiment of FIGS. 1-3;

[0009]FIGS. 4-6 are isometric views of another embodiment of the stapleof the present invention in formed, opened and deployed positions,respectively;

[0010]FIG. 7 depicts one embodiment of the stapler of the presentinvention;

[0011]FIG. 8 is an isometric view of the distal tip of the stapler ofFIG. 7 adapted to hold and deploy the staple of FIGS. 1-6;

[0012]FIGS. 9A-11B are isometric views of the cooperative movement ofthe distal tip of the stapler and the staple of the present invention;

[0013]FIGS. 12-15 are isometric views of an exemplary staple deploymentmechanism of the stapler of the present invention;

[0014]FIGS. 16 and 17 are isometric views of another exemplary stapledeployment mechanism of the stapler of the present invention;

[0015]FIGS. 18-26 depict various views of procedural embodiments of thepresent invention, including FIG. 20 depicting one embodiment of theintroducer of the present invention;

[0016]FIGS. 27-34 and 39 are isometric views of one exemplary embodimentof an introducer of the present invention;

[0017]FIGS. 35 and 36 are isometric views of another exemplaryembodiment of an introducer of the present invention; and

[0018]FIGS. 37 and 38 are isometric views of blood marking passagewaysof the introducer of the present invention.

DETAILED DESCRIPTION OF THE INVENTION

[0019] Tissue Staple

[0020] In one aspect of the present invention, a staple is provided toclose a tissue wound after a medical procedure. Although the preferreduse of the staple of the present invention is to close an artery or veinfollowing a diagnostic or interventional procedure, it should berecognized at the outset that the staple may be used for general tissuerepair, not just limited to vascular repair. It will be appreciatedthroughout the following description that the staple of the presentinvention can be formed of any biocompatible and/or bioabsorbablematerials, including, for example, Titanium (and Titanium alloys),stainless steel, polymeric materials (synthetic and/or natural),ceramic, etc. It will also be apparent from the following descriptionthat the staple of the present invention is preferably formed of adeformable material (such as those listed above) that undergoes plasticdeformation (i.e., deformation with negligible elastic component.) As ageneral overview, the staple of the present invention undergoes twopositions of deformation: a first position to extend the distal ends ofthe prongs of the staple outwardly to grab a greater amount of tissue(and also to grab tissue away from the wound locus), and a secondposition to move the prongs inwardly to close the wound.

[0021]FIGS. 1, 2 and 3 depict one embodiment of staple 10 of the presentinvention. FIG. 1 is the staple in it's formed position, FIG. 2 is thestaple just prior to deployment into tissue with the prongs extendedoutwardly, and FIG. 3 is the staple closed around tissue. The staple 10of this embodiment comprises a plurality of prongs 12A-12D and aplurality of tabs 14A-14D, arranged about a centerline axis 100. Commonportions, or shoulders 16A-16D are formed where the tabs meet theprongs. Each shoulder is common to both the prong and the tab and isgenerally defined by a relatively flat portion generally orthogonal tothe centerline axis. Shoulders 16A-16D may be viewed as an extension ofeach prong, bent inwardly toward the centerline axis. Each of thesefeatures of the staple 10 of this embodiment is detailed below.

[0022] In the formed position (FIG. 1), prongs 12A-12D extend generallyparallel to central axis 100, as shown. At the distal end of each prong,tapered points 18A-18D is formed to extend inwardly toward thecenterline axis 100. At the proximal end, shoulders 16A-16D meet atprongs 12A-12D, respectively. Tabs 14A-14D are generally U-shaped, andare formed between each prong. The proximal portions of each tab arejoined at consecutive shoulders, as shown. Each proximal portion of theU (i.e., each “leg” of the U-shape tab) extends first generally outwardfrom the shoulder, and second bends inwardly and distally towardcenterline axis 100, connecting together nearest the centerline axis toform the U shape. The U-shape defines slots 20A-20D within each tabhaving a base positioned at the bottom thereof.

[0023] Referring specifically to FIG. 2, the staple 10 is deformed sothat prongs 12A-12D extend outwardly from the centerline axis, prior todeployment into tissue. It is advantageous to extend the prongsoutwardly as shown so as to grasp a large portion of tissue, and so thatinsertion of the prongs into the tissue occurs at a locus away from thewound site, thereby providing a more consistent wound closure (byclosing the wound with more of the surrounding tissue) and ensuringcomplete (or near complete) closure of the wound. To deform the stapleinto the position shown in FIG. 2, a force F₁ is applied to tabs14A-14D, as shown in relief in FIG. 2A. Force F₁ is generally outward(from the centerline axis) and proximal to the top of the staple, asshown in relief in FIG. 2A. This force causes the tabs to move outwardfrom the centerline axis 100. The outward movement of the tabs causesthe shoulder portions to pivot roughly about the juncture between theshoulder and the prong (i.e., at the outer portion of the shoulder),causing the inner portions of the shoulders to move inwardly toward thecenterline axis and distally. Since the prongs are attached to the outerportion of the shoulders, the movement of the shoulders in this mannercauses the prongs to move outwardly. Thus, the cross-sectional diameterof the staple gets larger at the distal end (with respect to thecross-sectional diameter of the formed staple of FIG. 1). Note that themovement of the prongs is generally greater at the distal portionsthereof than at the proximal portions thereof. In other words, movementof the prongs as shown in FIG. 2 is pivoted from the shoulder, thusproducing a staple with outwardly extending prongs. For completeness, itshould be noted that a holding force may be applied downwardly (i.e.,substantially parallel to the centerline axis) against the base of theslots 20A-20D to hold the staple in place. Also, it is preferred thatthese forces are simultaneously applied to each tab of the staple toproduce uniform deformation of each prong of the staple. As mentionedabove, it is preferable that the plastic deformation of the staple issemi-permanent, so that the staple does not tend to return to the shapedepicted in FIG. 1 (i.e., non-elastic deformation). Deformation of thestaple into this position will be described in greater detail below inreference to the preferred stapler device of the present invention.

[0024]FIG. 3 depicts the staple 10 in a closed position. The closedposition, as stated herein generally means that the prongs of the stapleare moved inwardly toward each other. Although FIG. 3 depicts thetapered tip portions of the prongs meeting generally in the vicinity ofthe centerline axis, however, it should be understood that the term“closed” or “deployed” as used in reference to the staple need notnecessarily mean this precise configuration. It may be required (ordesirable) for some procedures to move the prongs inwardly toward eachother to a greater or lesser extent than as depicted in FIG. 3. To drawthe staple into the closed position depicted in this Figure, a force F₃is applied to the inner surfaces 30A-30D of the shoulders. This force isgenerally orthogonal to the centerline axis, and the angle between eachforce approximates the angle between the inner surfaces 30A-30D (which,in the staple of this embodiment is approximately 90 degrees). Thisforce causes the slots 20A-20D to spread apart and urges the shouldersoutwardly. Movement in this manner also causes the shoulders to moveoutwardly and proximally. Proximal movement of the shoulders causes theprongs to move toward each other. Opposite to the movement of FIG. 2,deformation shown in FIG. 3 results in an expanded cross-sectionaldiameter of the proximal end of staple, and a diminished cross-sectionaldiameter of the distal end of the staple (with respect to the formedstaple of FIG. 1 and the deformed staple of FIG. 2). Again, deformationof the staple 10 into this position will be described in greater detailbelow in reference to the preferred stapler device of the presentinvention.

[0025] For certain tissue application, it may be desirable that thestaple of the present invention is deployed into tissue such that theprongs do not fully pierce through the tissue, but rather grasp and holdthe tissue together. For example, for vascular closure applications itmay be desirable that the tissue piercing tapered ends not enter thebloodstream, but rather pierce into the tissue and stop short ofpiercing through the tissue wall. To that end, and referring to FIG. 3A,the staple 10′ of the present invention can be adapted with tissue stops32A-32D. Preferably, tissue stops 32A-32D are located along the lengthof each prong, and positioned from the distal tip of the prong to permitthe tapered ends to pierce tissue, but not pierce all the way throughthe tissue. Accordingly, the position of the stops 32A-32D along thelength of the prongs is selected to facilitate tissue grabbing (but notcomplete tissue piercing) and can vary from application to application.

[0026]FIGS. 4-6 depict another embodiment of a staple 50 of the presentinvention. FIG. 4 is the staple in it's formed position, FIG. 5 is thestaple just prior to deployment into tissue with the prongs extendedoutwardly, and FIG. 6 is the staple closed around tissue. Similar to thefirst embodiment, the staple 50 of this embodiment comprises a pluralityof prongs 52A-52D arranged about a centerline axis 100. A shoulder56A-56D is provided and is generally defined by a relatively flatsurface, generally orthogonal to centerline axis. Shoulders 56A-56D maybe viewed as an extension of each prong, bent inwardly toward thecenterline axis. In this embodiment, webs 54A-54D are connected to andbetween each prong, and are formed to extend inwardly from each prongtoward the centerline axis, creating a U shape generally orthogonal tothe centerline axis (as opposed to the previous embodiment in which theU-shaped tab is positioned generally parallel to the centerline axis).Each of the features of the staple 50 of this embodiment is detailedbelow.

[0027] In the formed position (FIG. 4), prongs 52A-52D extend generallyparallel to central axis 100, as shown. At the distal end of each prong,tapered points 58A-58D are formed to extend inwardly toward thecenterline axis 100. At the proximal end, shoulders 56A-56D meet atprongs 52A-52D, respectively. Web portions (webs) 54A-54D are generallyU-shaped, and are formed between each prong extending inwardly towardthe centerline axis. As shown, webs connect the prongs at a positiondistal to the shoulders. The precise position of the webs is determinedby the desired extent to which the prongs are extended outwardly, andthe extent to which the web curves inward toward the centerline axis.The space between the shoulders and the web portions defines a slot60A-60D.

[0028] Referring specifically to FIG. 5, the staple 50 is deformed sothat prongs 52A-52D extend outwardly from the centerline axis, prior todeployment into tissue. As with the previous embodiment, it isadvantageous to extend the prongs outwardly as shown so as to grasp alarge portion of tissue, and so that insertion of the prongs into thetissue occurs at a locus away from the wound site, thereby providing amore consistent wound closure (by closing the wound with more of thesurrounding tissue) and ensuring complete (or near complete) closure ofthe wound. To deform the staple into the position shown in FIG. 5, aforce F₁ is applied to webs 54A-54D, as shown in relief in FIG. 5A.Force F₁ is generally outward from the centerline axis and causes thewebs to deform outwardly, i.e. straightening the bend of the web bymoving the centermost point of the web outwardly. By deformation of theweb portions in this manner, the prongs move outwardly. Thus, thecross-sectional diameter of the staple gets larger at the distal end(with respect to the cross-sectional diameter of the formed staple ofFIG. 4). Note that the movement of the prongs is generally greater atthe distal portions thereof than at the proximal portions thereof, thusproducing a staple with outwardly extending prongs. For completeness, itshould be noted that a holding force may be applied downwardly (i.e.,substantially parallel to the centerline axis) against the top of thewebs in slots 60A-60D to hold the staple in place. Also, it is preferredthat these forces are simultaneously applied to each web of the stapleto produce uniform deformation of each prong of the staple. As mentionedabove, it is preferable that the deformation of the staple is plastic,so that the staple does not tend to return to the shape depicted in FIG.4. Deformation of the staple into this position will be described ingreater detail below in reference to the preferred stapler device of thepresent invention.

[0029]FIG. 6 depicts the staple 50 in a closed or deployed position. Theclosed position, as stated herein generally means that the prongs of thestaple are moved inwardly toward each other. To draw the staple into theclosed position depicted in this Figure, a force F₃ is applied to theinner surfaces 62A-62D of the shoulders. This force is generallyorthogonal to the centerline axis, and the angle between each forceapproximates the angle between the inner surfaces 62A-62D about thecenterline axis (which, in the staple of this embodiment isapproximately 90 degrees). This force urges the shoulders outwardly.Note that shoulders can only extend outwardly as far as the web portionswill permit. Outward movement of the shoulders causes the prongs to movetoward each other, since, there is a general pivot about the webportions. Opposite to the movement of FIG. 5, deformation shown in FIG.6 results in an expanded cross-sectional diameter of the proximal end ofstaple, and a diminished cross-sectional diameter of the distal end ofthe staple (with respect to the formed staple of FIG. 4 and the deformedstaple of FIG. 5). Again, deformation of the staple 50 into thisposition will be described in greater detail below in reference to thepreferred stapler device of the present invention.

[0030] In either embodiment described above, it should be evident thatalthough the Figures depict four each of the prongs, tabs and shoulders,this should be only be considered exemplary. It may be desirable toadapt the staple 10 or the staple 50 with more or fewer prongs, tabs andshoulders for a given application. Also, it is not necessary that eachprong is the same length, or that each prong has the same overalldimensions. In alternative embodiments, the entire staple, or selectedportions thereof can be alternatively fashioned from an elastic or shapememory (e.g., nitinol, and/or other elastic materials, including forexample temperature dependant shape memory materials) material therebypermitting elastic deformation from the a static closed position to anexpanded position and then elastically close about the wound. Also, theembodiment of FIGS. 4-6 can be adapted with a tissue stop positionedalong the length of the prong, as shown in FIG. 3A.

[0031] Stapler Device

[0032] Another aspect of the present invention is a stapler device todeploy the staple 10 of FIGS. 1-3, the staple 10′ of FIG. 3A, and thestaple 50 of FIGS. 4-6. As a general overview, the stapler of thepresent invention includes a distal tip for holding and deploying astaple, and an actuator mechanism to cause a staple, or at least thetissue piercing portions of a staple, to expand outwardly and then closeabout a wound. The stapler of the present invention facilitates oneobject of the present invention to ensure that the staple closes agreater amount of tissue as compared with conventional staplingmechanisms. The following description will detail various exemplarymechanisms to accomplish this goal, but it should be recognized thatnumerous alternatives will be readily apparent to those skilled in theart, and all such alternatives are to accomplish these objectives aredeemed within the scope of the present invention.

[0033]FIG. 7 depicts an isometric view of one embodiment of a staplingdevice 100 of the present invention. The device generally includes anactuation mechanism 104 and a distal tip 102. FIG. 8 is a more detailedview of the distal tip 102 of the stapler device 200. The distal tippreferably comprises an inner rod member 110 slidable within an outersleeve 112. Rod 110 includes a flared or mandrel portion 114. Mandrel114 also includes slots 118A-118D, which in use are aligned with fingers116A-116D. Fingers 116A-116D mate with slots 20A-20D and 60A-60D of thestaple 10 and 50, respectively. Preferably, rod 110 is removable forstaple attachment thereto, where a staple is positioned between themandrel and the sleeve. The mandrel, as will be described below, isresponsible for the forces generated on the staple.

[0034]FIGS. 9, 10A, 10B, 11A and 11B depict the working relationshipbetween the staple 10′ and/or 50 of the present invention and themandrel 114/sleeve 112 of the stapler mechanism 200. In FIG. 9A, thestaple 10′ is placed between the mandrel 114 and sleeve 112. Slots20A-20D of the staple engage fingers 116A-116D of the sleeve. The prongs12A-12D of the staple are dimensioned so as to fit over the mandrel, andtabs 14A-14D are dimensioned so as to fit over the rod 110, as shown.Similarly, for the staple 50 shown in FIG. 9B the staple 50 engages themandrel 114 and sleeve 112 (not shown). This is a static position, as noforces are applied to the staple to cause deformation. In FIG. 10A, thestaple 10′ is urged into the first deformed position (of FIG. 2) by therelative movement of the rod/mandrel and the sleeve. As shown, themandrel is urged proximally. As the mandrel moves, the tabs of thestaple meet the narrowest part of the mandrel. Further movement forcesthe tabs to move outwardly, causing the prongs to likewise moveoutwardly (as described above with reference to FIG. 2). Once the tabsclear the mandrel, outward movement of the tabs and prongs ceases.Similarly, in FIG. 10B, the movement of the mandrel forces webs toextend outwardly causing the prongs to extend outwardly (as describedabove with reference to FIG. 5). Once the webs clear the mandrel,outward movement of the prongs ceases. FIG. 1A depicts final deploymentof the staple into tissue. As the mandrel is drawn further proximallyand once the tabs have cleared the mandrel, the shoulders (not shown)are spread outward, forcing the prongs to move together (toward thecenterline axis) and closing tissue therebetween. FIG. 11B depicts thesame actuation, but for the staple 50 of FIGS. 4-6.

[0035]FIGS. 12-15 depict an exemplary actuator mechanism 104, showingthe relative motion of the sleeve 112 and the mandrel rod 110. Themechanism includes a cam 408 movable in a linear motion along a slot412. Movement of the cam can be manual or through an electronicallycontrollable motor (not shown). The cam 408 has lobes 408A and 408Clocated on a first side of the cam 408 and a lobe 408B located on asecond and opposing side of the cam 408. A first cam follower 418 iscoupled to the mandrel rod 110, and is selectably engagable with lobes408A and 408C. A second cam follower 416 is coupled to the sleeve 112,and is selectably engagable with lobe 408B. FIG. 12 depicts that neithercam follower is in contact with the lobes, and is indicative of aninitial position of the mechanism.

[0036]FIG. 13 depicts the mechanism 104 in a position to expand thestaple between the mandrel 114 and the sleeve 112, as shown in FIG. 9A.As cam 408 is moved (as indicated by the arrow), lobe 408A urges camfollower 418 along slot 426. The mandrel rod 110 is moved proximally,causing the prongs to extend outwardly (as shown in FIGS. 2 and 5) as aresult of the force of the mandrel 114 on the tabs or the web portions.With further movement of the cam 408 (FIG. 14), lobe 408B now urges camfollower 416 to move distally, thereby moving the sleeve distallyrelative to the mandrel rod and causing further expansion of the prongsand causing the staple to move distally. Finally, in FIG. 15, the cam isurged yet further and cam follower 418 is urged by lobe 408C causing themandrel and madrel rod to extend further proximally. This relativemovement between the cam rod and the sleeve causes the mandrel to applya force to the shoulder portions of the staple, in turn causing inwardmovement of the prongs. Lobe 408C causes closure of the prongs anddecouples the staple from the mandrel. This is the fully deployed staplemovement.

[0037]FIGS. 16 and 17 show an alternative cam mechanism. Similar to theprevious example, cam 608 is urged in a direction indicated by the arrowto cause relative motion between the mandrel rod and the sleeve. Lobes608A and 608B are located on opposite sides of cam 608. As the cam 608is moved along slot 612, the lobe 608A urges a cam follower 618 in alinear motion along a slot 626. This urges the cam follower 618proximally. The cam follower 618 is coupled to a mandrel rod 604. Thisdeforms staple 10/50 in the second configuration (see FIG. 2 or 5). Asthe cam 608 is urged further, the cam follower 618 moves distally tostay in contact with the lobe 608A. This urges mandrel rod 604 distally.The same movement of the cam 608 urges lobe 608B to urge cam follower616 distally. The cam follower 616 is coupled to a sleeve 606. Thisurges sleeve 606 distally. The downward slope of lobe 608A is parallelwith upward slope of lobe 608B so the mandrel rod 604 and the sleeve 606move distally in unison and the staple is advanced into the tissue. Themovement of the cam follower 618 down the slope of lobe 608A then ceaseswhile the movement of cam follower 616 continues up the slope of lobe608B, the staple 10/50 is deformed into the closed or deployedconfiguration (see FIG. 3 or 6). Springs 614 and 650 can be provided toreturn cam followers 616 and 618, respectively, to an initial position.Of course an additional spring can be provided in slot 612 to move cam608 back to an original position.

[0038] Alternatively, the actuation mechanism can include a rotatingdrum (not shown) to replace the cam 408 and 612. The drum may be adaptedwith lobes formed thereon, similar to lobes 408A-408C and 608A-608B,respectively. Other alternatives may include a rotating screw having avariable width in accordance with lobes 408A-408C or 608A-608B toactuate the mandrel rod and/or sleeve. Of course, instead of the cammechanisms depicted in the Figures, direct linkage may be used toactuate the mandrel rod and/or sleeve.

[0039] Wound Site Management

[0040]FIGS. 18-25A depict structural and procedural embodiments of woundsite management during and after a medical procedure, such asangioplasty. FIG. 18 depicts a conventional tubular dilator 500extending through the skin of a patient. Typically, the dilator 500 isleft in the skin following a completed medical procedure. When themedical procedure has been completed, the wound site must be stabilized.Although the blood flow may not be completely stopped, the blood flow isreduced to a point where the coagulants in the blood can complete thewound closure. To start the stabilization process of the wound site, thedoctor inserts a flexible guide wire 502 through an opening 504 in theend of the dilator 500. FIG. 19 shows the step of removing theintroducer 500 from the wound site after the guide wire 502 is properlyinserted through the skin and into the artery.

[0041] To facilitate efficient wound closure, another aspect of thepresent invention provides an introducer formed to stretch the woundsite for more efficient and effective closure. FIG. 20 depicts anexemplary introducer 510 of the present invention, and continues theprocess from FIGS. 18 and 19 where the introducer 510 slides over theguide wire 502 through an opening in the introducer 510 and a portion ofthe introducer is placed into the artery. Details of the introducer 510are disclosed below.

[0042]FIG. 20 depicts the introducer 510 inserted over the guide wire502 (already in the artery) and inserted into the artery. The introducerincludes a hollow elongated guide sheath 512 and dilator 520. Referringto FIG. 20A, the doctor urges the distal tip 516 of the dilator 520 intoand through the guide sheath 512 (over guide wire 502). A flexibledistal end 516 of the dilator 520 is inserted into the wound, until ablood marker BM indicates that the dilator 520 is properly positioned inthe artery. The blood marker BM located at a predetermined length alongthe dilator 520 allows blood to flow through a cavity 540 to alert thedoctor that the dilator 520, and more specifically the flexible distaltip 516, is properly inserted in an artery. Most preferable, the distaltip 516 of the dilator includes a tapered portion 522 to facilitateeasier ingress into the artery. An additional blood marking passageway(not shown) can be included on the distal end of sheath 512 asprecautionary indicator of the depth of the sheath. Presence of blood inthis additional passageway is indicative of the sheath being pressed toofar and into the arterial wall or into the artery. Of course, thoseskilled in the art will recognize that the introducer 510 will includeinternal passageways (lumens) for blood marking and the guide wire.

[0043] The diameter of distal end of the guide sheath 512 may be formedto expand if outward pressure is applied from inside surface of theguide sheath 512. For example, slits or weakened tear seams (describedbelow) may be formed in the distal end of the guide sheath 512 to allowthe diameter of the guide sheath to increase when pressure is applied.

[0044] One feature of the guide sheath of this exemplary embodiment isthe use of two or more wire guides 514 to maintain the sheath located onthe wound site, to provide approximation of opposing sides of the wound,to ensure that the closure device (e.g., stapler/staple, suturingdevice, cauterization, etc) remains located about the wound so that aclosure device is properly deployed, and to provide unobstructed accessto the wound site. In this embodiment, wire guides 514 are formed onopposing sides of the guide sheath 512. Having the wire guides 514 onopposing sides helps to ensure that not only is the sheath located onthe wound site, but that the sheath is approximately centered thereon.The wire guides are delivered into the artery by the dilator 520, asshown in FIGS. 21 and 26. The wire guides are removably coupled to thedistal end 516 of the dilator 520 and deployed into the wound, as shownin FIG. 26. The wire guides can be releasably held in openings or slots(not shown) on the sides of dilator. Once the dilator is properlyinserted into the wound to a proper depth (as indicated by the BMpassageway), the dilator is removed from the wound and the guide sheath.To remove the dilator 520 from the guide sheath 512, the doctor (orclinician) first holds the guide sheath 512 and advances the dilator 520inward (and upward) through the guide sheath 512. This decouples theguide wires 514A and 514B from the openings. To ensure that the wireguides 514A and 514B properly decouple from the dilator 520 before thedilator is withdrawn, a mechanism is provided that does not allowwithdrawal until the guide rod has been inserted a predetermineddistance. As shown in the drawing this mechanism can include a hubmechanism that requires a twisting motion or other action prior towithdrawal. After the guide rod has been inserted the predetermineddistance, the doctor extracts the guide rod. This leaves the guidesheath 512 centered on the wound with the wire guides 514A and 514Bextending inside the wound.

[0045] As is understood to those skilled in the diagnostic andinterventional arts, a puncture in an artery or vein has a generaltendency to manifest a slit or an elongated opening, since the cellstructure forming this tissue forms circumferentially (rather thanlongitudinally) to support radial expansion and contraction of thevessel. The wire guides 514A and 514B of the present enable the wound toapproximate the natural state of the wound, i.e., elongatedcircumferentially. The sheath may have a diameter approximately equal tothe diameter of the opening or wound, so that the distance between thewire guides 514A and 514B on the sides of the sheath approximatelyequals the diameter of the long axis of the wound, as best shown in FIG.23. Once inside the vessel, the wire guides 514A and 514B in thisposition limit movement of the sheath along the long axis, and since thewound is elongated, movement along the short axis is likewise limited.In this embodiment, since the wire guides 514A and 514B are disposed onopposing sides of the sheath, any device inserted through the sheathwill be approximately centered on the wound.

[0046] Importantly, since the wound opening tends to assume the shapeshown in FIG. 23 even in the absence of the wire guides, the opposingtissue located along the short axis tends to approximate. The presentinvention takes advantage of this tendency. If the position of the wireguides define a diameter larger than the diameter of the wound, thetissue along the short axis tends to approximate more, because thetissue on the long axis is stretched, thereby creating tension on thewound site. In other words, in this configuration, the wire guides forcethe tissue on either side of the wound to come together. It will beappreciated by those skilled in this art that the amount of tensionrequired will be tissue dependant, and thus, the overall diameter of thesheath and wire guides should be sized according to the wound size andtissue strength, and should not be sized to cause a tear in the tissue.For example, vascular tissue is relatively elastic, and can toleratemore tension than other tissues (e.g., dura-matter, duct tissue, bladdertissue, etc.). The sheath and dilator of the present invention takethese factors into consideration and are accordingly sized for theparticular tissue application. However, sufficient wound site managementaccording to the present invention does not require that the wire guidesstretch the wound. Rather, if the position of the wire guides is shorterthan the wound length, the wire guides still serve to maintain thesheath generally located (and possibly centered) on the wound. In bothcircumstances, the wire guides ensure that a closure (e.g., staple)deployment is more accurate. When tension is created on the wound site,a certain amount of tissue is available, which may be advantageouslygrasped by the staple for closure. Also, if the wound opening in thetissue is held taught by the sheath/wire guides, there is less tendencyfor the tissue surrounding the opening to slip down into the vesselduring staple deployment (which would reduce the effectiveness of theclosure).

[0047]FIG. 23 also shows examples of locations S1, S2, S3, and S4 ofwhere the prongs of the staple to be inserted will line-up relative tothe wound opening WO. The wire guides 514 are depicted disposed onopposing sides of the guide sheath 512, and more specifically, the wireguides are inserted into the wound opening along the long axis of theartery or vein, so that the wound is pulled taught along the long axis.

[0048]FIG. 22 shows the distal end of a stapler 104 with a staple 10/50being inserted through the guide sheath 512 of the introducer 510. FIG.22A depicts a relief view of the introducer 510, and more clearlydepicts the slits or weakened tear seams 700. When the distal end of thestapler 104 is properly inserted in the guide sheath 512, the staple canbe deployed into the tissue. FIG. 24 shows the first step of stapledeployment, the process of which is described in detail above. Note thatin FIG. 24A, the extension of the staple prongs causes the weakened tearseam or slits to separate. This further causes the wire guides to expandagainst the long axis of the wound, thereby further approximating thetissue surrounding the opening. The diameter formed by the prongs of thestaple 10/50 is now larger than the original outside diameter of theguide sheath 512. FIGS. 25 and 25A depict the staple fully deployed intotissue, the process of which is described above. The stapler can now beremoved from the guide sheath 512. The guide sheath 512 can now be urgedaway from the wound opening WO and the guide wires 514A and 514B areextracted from the closed opening.

[0049] In an alternative exemplary embodiment, instead of using wireguides, a single loop actuation wire 654 is used, as in the exemplaryintroducer assembly 510′ illustrated in FIGS. 27-32. The exemplaryintroducer assembly 510′ is slidably disposed about a central guide wire672 and comprises a guide rod 670 and a guide sheath 662. The guidesheath 662 includes a plurality of wire stabilization guides 660, whichmay be integrated into the guide sheath 662, or alternatively, be formedseparately and coupled thereto. The wire stabilization guides 660generally comprise tubular members disposed around the outside diameterof the sheath, to hold the end portions 656, 657 of the loop actuationwire 654. Guide sheath 662 is a tubular and has a circularcross-sectional shape, and has an inside diameter dimensioned to slideover the guide rod 670. It is equally contemplated that the guide sheathhas an oval or non-circular cross-sectional shape. The sheath furtherincludes one or more slits or weakened tear seams 686 to providecontrolled expansion of portions of the guide sheath, as will bedetailed below.

[0050] The guide rod 670 is a tubular member and includes at least oneslot 682 formed therein for releasably holding the loop actuation wire654. As shown in FIG. 27, the guide rod has a main tubular bodydimensioned to fit inside the guide sheath and has a tapered end 800having an opening 802 at the tip to accept the central guide wire. Toreleasably hold the actuation wire, at least one longitudinal slot 682may be formed in the guide rod 670 along its length. To permit temporaryholding and controlled release of the loop actuation wire 654, the widthof the longitudinal slot 682 at the surface of the guide rod 670 shouldbe less than the outside diameter of the stabilization guides 660 or theloop actuation wire 654, so that the stabilization guide and/or loopactuation wire 654 is held within the slot (as shown in FIG. 27) untilreleased by the sliding action of the sheath over the guide rod, asdescribed below. The loop actuation wire and/or wire guides can be heldin a slot or slit formed in the guide rod (which may define a separatelumen structure in the guide rod), or alternatively the slot can beformed with a diameter less than the width of the wire or wirestabilization guide to permit the wire or wire stabilization guide tofriction fit into the slot. As shown in FIGS. 27-29, the slot 682 may bebounded by a pair of recessed areas 658, 659, so that, for example, thewire does not catch on tissue as the guide rod is inserted and removedfrom an artery or vein. Alternatively, instead of defined slots formedin the guide rod, slits (not shown) may be formed in the material of therod such that the loop actuation wire 654 is releasably held to theguide rod in a friction fit manner, and released from the guide rod in asimilar manner as described above.

[0051] In this configuration, one end portion 656 of the loop actuationwire 654 is threaded inwardly into one end of the slot 682 at the firstrecessed area 658 and back outwardly from the slot 682 at the secondrecessed area 659 in the guide rod 670. Similarly, the other end portion657 of the loop actuation wire 654 may be threaded through a second slot(not shown), which may optionally include a set of recessed areas (notshown) on the opposing side of the guide rod 670, or elsewhere along itslength. The slot 682 may be located along the length of the guide rod670. For example, as shown in FIGS. 27-32, the slot 682 is located alonga line parallel to the central axis of the guide rod 670. Of course, itis not a requirement of the present invention that the slot be formed inthis manner, nor that the slot include recessed areas at its ends. Asused herein with reference to the location of the slot(s) 682 and/orrecessed areas 658, 659, the phrase “along the length of the guide rod”or “along its length” may mean generally longitudinally along thecentral axis of the guide rod, or may alternatively mean a slot formedin any orientation, since the slot and/or recessed areas 658, 659 merelyserve to releasably hold the wire stabilization guides 660 and/or ends656, 657 of the loop activation wire in place, and one of any number ofconfigurations of slot 682 and/or recessed areas 658, 659 may suffice.While not necessary to provide operability to the present invention, anopening 804 within the guide rod may be provide to expose a portion ofthe central guide wire 672. The central guide wire 672 can then beplaced over the loop portion 680 of the loop actuation wire 654 tosecure the loop to the guide rod until the central guide wire isremoved. The foregoing assumed that the wire forming the wire actuationloop has a generally circular cross section. However, alternativelyother wire shapes may be used, in which case the wire stabilizationguides 660 and slot 682 may comprise one or more internal matingcomponents adapted to mate with end portions 656, 657 of the loopactuation wire 654, in which case the end portions 656, 657 wouldcomprise one or more appropriate corresponding mating components.

[0052]FIGS. 39 and 39A depict cross-sectional views of the guide rod 670of this exemplary embodiment. The guide rod 670, as depicted in FIG. 40,includes a plurality of lumens: 802, 804, 806 and 808. Lumens 808 and806 are included as a blood marking passageway (described above) and awire guide passageway, respectively. Lumens 806 and 808 are shownadjacent one another, but these lumens could also be formed coaxial withon another (e.g., the wire guide lumen inside of the blood markinglumen). Lumens 802 and 804 releasably hold the loop actuation wiretherein, and run along the length of the guide rod, for example, asshown in FIG. 27. Lumens 802 and 804 are shown on opposing sides of theguide rod. But it is equally contemplated that the lumens need not bedisposed at opposition, but rather may be formed at any angle withrespect to one another. A slit 810 may be provided such that the loopactuation wire is held in lumen 802/804 until outward pressure forcesthe wire to “pop” out of the slit 810. To that end, the materialsurrounding the slit may comprise material of reduced durometer (withrespect to the rest of the guide rod) such that the actuation wire canslide into and out of the lumen. Alternatively, instead of a slit, aslot may be formed as depicted in FIG. 40A. The slot 812 is defined bytruncated lobes 814 and 816. Lobes 814 and 816 may also comprisematerial of reduced durometer with respect to the remaining portions ofthe guide rod. Slot 812 can be dimensioned for a particular gage wireinserted therein. Although lumens 804 and 802 are depicted as havinggenerally circular cross-sectional shapes, the present invention equallycontemplates other shapes, as may be dictated by the cross-sectionalshape of the loop actuation wire (although the cross sectional shape ofthe wire stabilization guide, loop actuation wire and the lumen need notmatch).

[0053] The use of the foregoing described exemplary introducer 510′ willnow proceed with reference to FIGS. 27-32. As FIG. 27 illustrates, theintroducer 510′ is initially inserted into the percutaneous punctureover the central guide wire 672 (already in the artery), which tracksinto the puncture site, and is inserted into the artery. Once it hasbeen determined that the distal end of the guide sheath 662 has reachedthe approximate location of the artery or venous outer wall, the centralguide wire 672 may be removed from the introducer assembly 510′, asshown. As shown in FIG. 28, removing the central guide wire 672 allowsthe loop activation wire 654 to be freely released from the guide rod670 through the longitudinal apertures 682 within the guide rod 670.This is accomplished by withdrawing the guide rod 670 from the guidesheath 662 as shown in FIGS. 28 and 29. Removing the guide rod from theguide sheath forces the wire stabilization guides 660 (and the loopactivation wire within) out of the slots 682 defined in the guide rod byvirtue of the force of the end of the sheath on the wire stabilizationguides as the guide rod slides proximally out of the sheath, whereuponthe loop actuation wire 654 and wire stabilization guides 660 arereleased to form an open loop, as shown in FIG. 29. The guide rod 670may then be completely withdrawn from the guide sheath 662.

[0054] As FIGS. 30 and 31 illustrate, the stabilization guides 660 maybe secured and actuated by pulling the loop actuation wire 654 at one orboth end portions 656, 657 until the distal ends of the stabilizationguides 660 approximate to form a stabilization loop portion 680.Preferably, slits 686 or weakened tear seams (slits and weakened tearseams are used synomously herein) are formed in the distal end of theguide sheath 662 to allow the diameter of the guide sheath 662 toincrease when an outwardly radial force is applied to the distal end ofthe guide sheath 662, for example by the expansion of the loop portionof the loop actuation wire 654. The foregoing action provides opposingforces outwardly to the central axis of the guide sheath 662, therebycausing the end of the guide sheath 662 to separate at its slits 686.Additional clearance for the expansion of a closure device (not shown)within the guide sheath 662 is thus provided. Furthermore, the tissuethat is stretched by the stabilization guides 660 is caused to slidealong the newly ramped angles of the stabilization guides 660 and beforced against the distal end of the guide sheath 662. Moreover, theforegoing action aids in retaining the guide sheath 662 within thepuncture against the vessel. The closure modality (e.g., a staple, asdescribed hereinabove) may next be delivered. As shown in FIG. 32,tension may then be applied to a single end 657 of the loop actuationwire 654 until the wire 654 is completely removed from the plurality ofstabilization guides 660, thereby freeing the distal ends of thestabilization guides 660 and allowing them to slide out of the vesselpuncture on either side of the closure device (not shown). Finally, theguide sheath 662 assembly may be removed from the puncture site.

[0055] The wire stabilization guides 660A and 660B depicted in FIGS.30-32 are generally formed as tubular structures having an insidediameter sufficient to pass the wire ends 656, 657 therethrough. Theguide 660A and 660B are drawn together (FIG. 31) to form the loop. As ageneral matter, the wire stabilization guides 660A and 660B incombination with the loop activation wire add to the stiffness of thecombined area, since it is intended that the closure of the guidescauses sufficient outward force to expand the sheath along the slot orweakened tear seams, i.e. by creating a loop causing these outwardforces. Note that the Figures depict wire guide 660A longer than 660B,however, it is not essential that the lengths of the wire guides are asdepicted. Rather, the lengths may be selected to be equal or non-equalwithout departing from the present invention. The positions of the wireguides 660A and 660B are depicted on opposing sides of the sheath. Whilethis arrangement will provide a more accurate centering of the sheath onthe wound site, it is contemplated herein that for certain procedurescentering on the wound site may not be necessary, critical, or accurate,and thus, the positions of the wire stabilization guides can be atlocations about the sheath other than at opposition.

[0056] Note also that the description of the slots in the guide rod toreleasably hold the wire stabilization guides are formed in a locationmost convenient for placing the wire guides into the slots. Also, theslots may be defined such that one slot releasably holds the wirestabilization guide with the wire inserted therethrough, and the otherslot is dimensioned to releasably hold just the wire (as may be the casewhen the lengths of the wire stabilization guides differ). Still othermodification may be made.

[0057] Thus, a single or multi-lumen sheath device may be stabilized indirect approximation to an arterial, venous or other lumenal puncture.Advantageously, the foregoing described method allows the positioning ofa closure modality directly centered over such a puncture. The foregoingdescribed introducer assembly 510′ allows the distal end of the sheath662 through which the closure device is introduced to be drawn againstthe artery, vein or other lumen, thereby aiding in sealing the puncturesite to prevent leakage, as well as stabilizing the sheath 662 directlyover the wound site.

[0058] As FIGS. 35 and 36 illustrate, in another embodiment, theforegoing described stabilization loop portion may be replaced with astabilization loop portion 680′ comprising a loop actuation wire 654having at least one reinforced section 666. The reinforced section maycomprise an area of increased material or combination of materials,e.g., a section of the actuation wire 654 or stabilization guide 660with greater individual or combined rigidity. In this configuration, thelocation of the reinforced section 666 may be manipulated with respectto the wound site to control the shape of the stabilization loop portion680′. The stabilization guides 660 may be secured and actuated bypulling the loop actuation wire 654 at one or both end portions 656, 657until the distal ends of the stabilization guides 660 approximate toform a stabilization loop portion 680′ which comprises the reinforcedsection 666, the central axis of which is generally perpendicular to thecentral axis of the guide sheath 662, thereby providing opposing forcesoutwardly perpendicular to the central axis of the guide sheath 662 andcausing the end of the guide sheath 662 to separate at its slits 686. Asshown in FIG. 36, the loop portion and reinforced section forms a shapewith the general appearance of coat hanger. Additional clearance for theexpansion of a closure device (not shown) within the guide sheath 662may likewise be provided.

[0059] As in the previously described embodiment, the tissue which isstretched by the stabilization guides 660 is caused to slide along thenewly ramped angles of the stabilization guides 660 and be forcedagainst the distal end of the guide sheath 662. The foregoing actionaids in retaining the guide sheath 662 within the puncture against thevessel. The closure modality (e.g., a staple, as described hereinabove)may next be delivered. As shown in FIG. 32, tension may then be appliedto a single end 657 of the loop actuation wire 654 until the wire 654 iscompletely removed from the plurality of stabilization guides 660,thereby freeing the distal ends of the stabilization guides 660 andallowing them to slide out of the vessel puncture on either side of theclosure device (not shown). Finally, the guide sheath 662 assembly maybe removed from the puncture site. As those skilled in the art willrecognize, in the foregoing described procedure illustrated in FIGS.27-32, it is necessary for the doctor to determine the point at whichthe distal end of the guide sheath 662 has reached the approximatelocation of the artery or venous outer wall prior to removing thecentral guide wire 672 from the introducer assembly 510′. One exemplarymethod for identifying insertion depth of a transluminal device will nowbe described with reference to FIGS. 33 and 34. As shown, two “flashback” blood marking lumens 689 are fixedly attached to the guide sheath662. The distal end of the first blood marking lumen is at aninterluminal blood marking port 674 located at a predetermined pointalong the guide rod 670, and the proximal end of the first blood markinglumen is an interluminal flashback port 684 for observing the presenceof blood at the interluminal blood marking port 674. The distal end ofthe second blood marking lumen is an extraluminal blood marking port 675located approximately at the distal end of the guide sheath 662, and theproximal end of the second blood marking lumen is an extraluminalflashback port 688 for observing the presence of blood at theextraluminal blood marking port 675.

[0060] In operation, the introducer assembly 510′ is introduced into thepercutaneous puncture which tracks into the puncture site, as describedhereinabove. The location at which the guide sheath 662 has reached theapproximate location of the artery or venous outer wall may beidentified by observing the pressurized blood flow from the internalflashback port 684, which enters the internal blood marking port 674when the internal blood marking port 674 has reached the inner lumen ofthe vessel. The absence of pressurized blood flow observed at theinternal flashback port 684 indicates that the guide sheath 662 has notyet reached the vessel outer wall. The fact that the guide sheath 662has not entered the inner lumen of the vessel may be confirmed by theabsence of pressurized blood flow observed at the external flashbackport 688, which enters the extraluminal blood marking port 675 only ifthe extraluminal blood marking port 675 has reached the inner lumen ofthe vessel. Likewise, presence of blood in this lumen indicates theguide is too far into the artery or vein. The presence of pressurizedblood flow at the internal flashback port 684 and absence of pressurizedblood flow at the external flashback port 688 indicate that the distalend of the guide sheath 662 is adjacent to the arterial or venous outerwall.

[0061]FIGS. 37 and 38 depict alternative embodiments for bloodmarking.In FIG. 37, the BM lumen 540 includes a sensor 700 (e.g., differentialpressure transducer, flow sensor, electrodes, etc.) to detect thepresence of fluid or fluid flow thereon. The wiring for the sensor canbe routed through the lumen 540, as shown, to transmit a signal of thepressure (or presence of fluid) at the sensor 700. In FIG. 38, anoptical fiber 702 is placed in lumen 540 for direct viewing of the areaaround BM port.

[0062] Thus, the foregoing-described steps provide a method foridentifying the depth of insertion of the transluminal device into anartery or vein based on the presence of pressurized blood internal tothe vessel and the absence of pressurized blood external to the vessel.Alternatively, more than two blood marking points, lumens, and ports maybe provided to further aid in determining precisely the depth of theinserted transluminal device. Furthermore, it is contemplated that theforegoing described insertion depth identifying technique may haveutility in other contexts, as well, and those skilled in the art willrecognize that the foregoing technique should not be limited to thecontext described hereinabove.

[0063] As described above, either the stabilization loop portion 680 or680′, or the guide sheath 662 may therefore be approximated to tissuesurrounding the wound site, so as to cause spring tension against thesurrounding tissue, thereby aiding in approximately centering anintroducer about the wound site, as well as in allowing opposing sidesof the tissue surrounding the wound site to approximate one another. Itis further contemplated that alternatives of the embodiments describedabove may be implemented consistent with the invention for stretchingthe wound site and for centrally locating procedures at the wound site.For example, in the above-described embodiments, loop portions 680 and680′ provide a force to the wire and the guide sheath to spread thesheath outwardly and to approximate opposing portions of the wound site,as shown and described. However, in still other embodiments, the guidesheath can be formed having a biasing mechanism that forces the sheathinto the opened or spread position as shown in FIGS. 31 and 36. To thatend, this sheath may further comprise members on either side (such asthe wire guides or shortened variations thereof shown in the embodimentof FIGS. 20A-22A) that provide the aforementioned outwardly opposingforces on the tissue surrounding the wound site.

[0064] There are many alternatives to the foregoing description of FIGS.27-40 that will be apparent to those skilled in the art. For example,the wire forming the loop structure described herein may be provided asa single continuous loop that is pre-threaded into the wirestabilization guides. In this case, the loop is closed by pulling on thefree end of the loop. The wire may be snipped or cut so that it can bepulled free of the sheath and the wire stabilization guides. Othermodifications may be made. For example, the sheath may be adapted withholding mechanisms (not shown) to hold the ends of the wire in placeonce the doctor has pulled on the free ends to form the loop. Stillother modifications may be made. For example, instead of using wire incooperation with the tubular wire stabilization guides to for the loop,the present invention contemplates that this arrangement can be replacedwith a single elongated member (e.g. similar to the wire stabilizationguide described herein) affixed to the guide sheath on opposing sides sothat pulling this member forms the loop as shown in the drawings. Inother words, the wire stabilization guide and wire described above maybe replaced with a single member of sufficient modulus to for the loopas set forth herein.

[0065] The wire described herein may comprise a tube, filament, strandedfilaments, or other structures that are equivalent.

[0066] Still other modifications can be made. For example thestabilization guides have been described herein as being generallytubular so that wire can be threaded therethrough. However, this is onlyan exemplary arrangement. The stabilization guides and wire could becoupled together in other configuration, for example, sliding engagementthat may comprise a tongue-and-groove coupling, dovetail coupling, orother arrangement that would permit relative motion between thestabilization guides and the wire, while still providing mechanicalstrength along at least one axis. Although the present invention hasbeen described in relation to particular embodiments thereof, many othervariations and modifications and other uses will become apparent tothose skilled in the art. It is preferred, therefore, that the presentinvention be limited not by the specific disclosure herein, but only bythe appended claims.

1-22 (canceled)
 23. An introducer comprising: a sheath comprising meansfor producing outwardly opposing forces, wherein when said sheath isapproximated to a wound site and said means for producing outwardlyopposing forces is activated, opposing sides of the tissue surroundingsaid wound site are caused to approximate one another.
 24. Theintroducer of claim 23, wherein when said sheath is approximated to saidwound site and said means for producing outwardly opposing forces isactivated, said sheath is held approximately centered on said woundsite.
 25. A method for stabilizing a wound site comprising:approximating to a wound site the sheath of an introducer, said sheathcomprising means for producing outwardly opposing forces; and activatingsaid means for producing outwardly opposing forces, so as to causeopposing sides of the tissue surrounding said wound site to approximateone another.
 26. The method of claim 25, wherein when said sheath isapproximated to said wound site and said means for producing outwardlyopposing forces is activated, said sheath is held approximately centeredon said wound site. 27 (cancelled) 28 (cancelled)
 29. A method fordetermining the depth of a transluminal device with respect to a woundsite located at an artery or vein, said method comprising: coupling atleast a first and a second blood marking lumen to said device, each saidlumen having a flashback port at a first end and a blood marking port ata second end, the blood marking port of the first said lumen beingfixedly disposed to said device at a shorter distance from said woundsite than the blood marking port of said second lumen; introducing saidtransluminal device into said wound site; and observing said lumensuntil pressurized blood flow is present at the first said lumen andabsent at said second lumen, wherein the fact that the blood markingport of the first lumen is adjacent to the outer wall of said artery orvein is indicated. 30-33 (canceled)
 34. An introducer, comprising: atubular sheath having a wire stabilization guide having at least aportion thereof extending from an end of said sheath; said wirestabilization guide comprising a reinforced section disposed along atleast a portion of said wire stabilization guide extending from saidsheath; a guide rod sized to fit within said tubular sheath and having aslot formed along its length, said slot releaseably holding said wirestabilization guide; a wire having two ends, one end slidably coupled tosaid wire stabilization guide, the other end attached to said guidesheath, and thus forming a loop of wire from the wire protruding fromsaid wire stabilization guide extending from said end of said sheath,wherein said reinforced section causing said loop of wire to extend in adirection generally perpendicular to the long axis of said guide rod andsaid sheath.
 35. An introducer, comprising: a tubular sheath having awire stabilization guide, said wire stabilization guide comprising anelongated tubular member having at least a portion thereof extendingfrom an end of said sheath; a reinforced section disposed on a portionof said wire stabilization guide extending from said sheath; a guide rodsized to fit within said tubular sheath and having a slot formed alongits length, said slot releaseably holding said wire stabilization guide;a wire having two ends, one end threaded into said wire stabilizationguide, the other end attached to said guide sheath, and thus forming aloop of wire from the wire protruding from said wire stabilization guideextending from said end of said sheath, wherein said reinforced sectioncausing said loop of wire to extend in a direction generallyperpendicular to the long axis of said guide rod and said sheath.
 36. Anintroducer comprising: a sheath; and a stabilization loop extending froman end of said sheath, said stabilization loop comprising an actuationwire, said stabilization loop expanding outwardly from said sheath whenin a deployed configuration.
 37. An introducer according to claim 36wherein a region of said stabilization loop adjacent said end of saidsheath is angled outwardly from said sheath in a deployed configuration.38. An introducer according to claim 36 wherein said stabilization loopcomprises at least one stabilization guide, at least a portion of saidstabilization guide extending from said end of said sheath, wherein insaid deployed configuration a distal end of said stabilization guideapproximates said end of said sheath to form an expanded loop.
 39. Anintroducer according to claim 36 wherein said stabilization loopcomprises first and second stabilization guides, at least a portion ofeach stabilization guide extending from said sheath, in said deployedconfiguration a distal end of said first stabilization guideapproximates a distal end of said second stabilization guide forming anexpanded loop.
 40. An introducer according to claim 39, wherein saidactuation wire extends between said distal ends of said stabilizationguides.
 41. An introducer according to claim 40 wherein said actuationwire is slidably disposed in at least one of the first and secondstabilization guides.
 42. An introducer according to claim 39 whereinsaid two stabilization guides are positioned on opposite sides of thesheath.
 43. An introducer according to claim 39 wherein said twostabilization guides extend an equal length from said sheath.
 44. Anintroducer according to claim 39 wherein said two stabilization guidesextend an unequal length from said sheath.
 45. An introducer accordingto claim 36 wherein said actuation wire comprises at least onereinforced section, said reinforced section having an orientationgenerally perpendicular to a central axis of said sheath when saidstabilization loop is in said deployed configuration.
 46. An introduceraccording to claim 36 wherein said sheath comprises at least one tearseam extending from said end of said sheath.
 47. An introducer accordingto claim 46 wherein said sheath comprises at least one tear seamextending from said end of said sheath disposed on each side of saidstabilization loop.
 48. An introducer according to claim 36 furthercomprising a guide rod dimensioned to be slidably received within saidsheath.
 49. An introducer according to claim 48 wherein said guide rodcomprises at least one recess sized to releasably retain at least aportion of said actuation wire.
 50. A method of stabilizing a woundcomprising: providing an introducer comprising a sheath having astabilization loop extending from an end of said sheath; inserting atleast a portion of stabilization loop in an un-deployed configurationinto a wound, deploying said stabilization loop, wherein saidstabilization loop expands outwardly.
 51. A method according to claim 50wherein said stabilization loop comprises an actuation wire anddeploying said stabilization loop comprises retracting said actuationwire.
 52. A method according to claim 51 wherein said stabilization loopcomprises at least one stabilization guide extending from said end ofsaid sheath, and deploying said stabilization loop comprisesapproximating a distal end of said stabilization guide to said end ofsaid sheath.
 53. A method according to claim 51 wherein saidstabilization loop comprises a reinforced section of said actuationwire, and deploying said stabilization loop orients said reinforcedsection generally perpendicular to a central axis of said sheath.
 54. Amethod according to claim 50 wherein deploying said stabilization loopexpands said end of said sheath.
 55. A method according to claim 54wherein deploying said stabilization loop separates at least one slit insaid end of said sheath.
 56. A method according to claim 50 wherein saidintroducer comprises a guide rod slidable within said sheath, andinserting at least a portion of stabilization loop in an un-deployedconfiguration into a wound comprises releasably retaining at least aportion of said stabilization loop to said guide rod and inserting atleast a portion of said guide rod into said wound.
 57. A methodaccording to claim 56 wherein releasably retaining at least a portion ofsaid stabilization loop to said guide rod comprises disposing at least aportion of said stabilization loop in a recess in said guide rod.
 58. Amethod according to claim 50 wherein deploying said stabilization loopangles said stabilization loop outwardly adjacent said sheath.
 59. Amethod according to claim 58 wherein said outwardly angled stabilizationloop applies outward forces on opposed sides of said wound.
 60. A methodaccording to 58 wherein said outwardly angled stabilization loop urgessaid sheath toward said wound.